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Qualified Entity Certification Program
Paper-Based Reapplication Form
Version 1.0

Paper-Based
Reapplication Form

Table of Contents
1. Paper-Based Reapplication..................................................................................................................... 1
2. Reapplication Requirements .................................................................................................................. 2
Element 1.1............................................................................................................................................... 2
Element 1.4............................................................................................................................................... 2
Element 2.1............................................................................................................................................... 2
Element 2.2............................................................................................................................................... 3
Elements 2.3 & 2.4 ................................................................................................................................... 3
Element 3.1............................................................................................................................................... 4
Element 3.2............................................................................................................................................... 4
Element 3.3............................................................................................................................................... 4
Appendix A: Additional Attachments............................................................................................................ 6
Appendix B: Minimum Requirements Review .............................................................................................. 7

List of Tables

Table 1: Organization Information ................................................................................................................ 1
Table 2: Application Submission ................................................................................................................... 1
Table 3: Application Receipt ......................................................................................................................... 1
Table 4: Statement 1 Responses ................................................................................................................... 2
Table 5: Statement 2 Responses ................................................................................................................... 2
Table 6: Statement 3 Responses ................................................................................................................... 2
Table 7: Statement 4 Responses ................................................................................................................... 3
Table 8: Statement 5 Responses ................................................................................................................... 3
Table 9: Statement 6 Responses ................................................................................................................... 3
Table 10: Statement 7 Responses ................................................................................................................. 4
Table 11: Statement 8 Responses ................................................................................................................. 4
Table 12: Statement 9 Responses ................................................................................................................. 4
Table 13: Statement 10 Responses ............................................................................................................... 5
Table 14: Element 1.1 Requirements............................................................................................................ 7
Table 15: Element 1.4 Requirements............................................................................................................ 7
Table 16: Element 2.1 Requirements............................................................................................................ 9
Table 17: Elements 2.3 & 2.4 Requirements .............................................................................................. 10
Table 18: Element 3.1 Requirements...................................................................................................... 1110
Table 19: Element 3.2 Requirements...................................................................................................... 1211
Table 20: Element 3.3 Requirements...................................................................................................... 1211

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1.

Paper-Based Reapplication

Directions: Complete the gray form fields in each table. Submit the complete application to QECP
Support. You may also contact QECP Support with any questions.
Note: The time to complete this information collection is an estimated average of 120 hours per
response, including the time to review instructions, search existing data sources, gather the data, and
complete and review the information collection.
Table 1: Organization Information
Category
Organization Name

Details
Organization Name

Table 2: Application Submission
Category
Date Reapplication Submitted

Details
MM/DD/YYYY

Table 3: Application Receipt
Category
Date Reapplication Received by CMS

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Details
MM/DD/YYYY

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2.

Reapplication Requirements

This section covers Reapplication requirements. After each of the following Element headings, there are
application requirements and statement(s). Respond to each statement in the corresponding table.
Refer to Appendix B for Reapplication requirement details.

Element 1.1
Identify changes to the QE’s organization.
Statement 1: Your organization intends to continue to contract with the same organization(s) to fulfill
the QECP requirements.
Table 4: Statement 1 Responses
Category
PM Pre-Fill

Details
Insert Text

Self-Assessment

Change, No Change, or Not Applicable (NA)

Explanation of Self-Assessment

Insert Text

Element 1.4
Identify changes to the QE’s ability to obtain other-payer claims data.
Statement 2: Your organization still receives the same sources and amounts of other-payer claims data
for the approved geographic areas in the pre-filled text box below..
Table 5: Statement 2 Responses
Category

Details

PM Pre-Fill

Insert Text

Self-Assessment

Change, No Change, or NA

Explanation of Self-Assessment

Insert Text

Element 2.1
Identify changes to the QE’s data security.
Statement 3: The data flow diagram submitted by your organization still accurately demonstrates 1)
how sites that access the QE Medicare data are connected, and 2) how QE Medicare data flow through
your organization from receipt to public reporting (including the confidential provider Corrections and
Appeals process).
Table 6: Statement 3 Responses
Category
PM Pre-Fill
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Details
Insert Text
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Category

Details

Self-Assessment

Change, No Change, or NA

Explanation of Self-Assessment

Insert Text

Statement 4: Since Phase 2 approval, or submission of your organization’s most recent QECP annual
report, your organization has made significant changes to the data security environment and practices.
Table 7: Statement 4 Responses
Category

Details

PM Pre-Fill

Insert Text

Self-Assessment

Change, No Change, or NA

Explanation of Self-Assessment

Insert Text

Element 2.2
Identify changes to QE’s Public and Non-Public Reporting Levels.
Statement 5: Your organization’s attestations provided in the application still accurately demonstrates
your planned level of reporting (regional or provider identified) within public reports and non-public
analysis. Your organization would like to change their level of reporting (provider-identified vs regional)
prior to the next reporting cycle for either public or non-public reports.
Table 8: Statement 5 Responses
Category

Details

PM Pre-Fill

Insert Text

Self-Assessment

Change, No Change, or NA

Explanation of Self-Assessment

Insert Text

Elements 2.3 & 2.4
Identify changes to the Corrections and Appeals process.
Statement 6: Your organization would like to make changes to their Corrections and Appeals process
prior to the next reporting cycle. This includes any changes to your organization’s privacy and security
protections for the release of beneficiary identifiers and/or claims data to providers.
Table 9: Statement 6 Responses
Category

Details

PM Pre-Fill

Insert Text

Self-Assessment

Change, No Change, or NA

Explanation of Self-Assessment

Insert Text

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Paper-Based
Reapplication Form

Element 3.1
Identify changes to Standard Measures.
Statement 7: Your organization intends to continue reporting the same Standard Measures in its next
public reporting cycle.
Table 10: Statement 7 Responses
Category

Details

PM Pre-Fill

Insert Text

Self-Assessment

Change, No Change, or NA

Explanation of Self-Assessment

Insert Text

Element 3.2
Identify changes to Alternative Measures.
Statement 8: Your organization intends to continue reporting the same Alternative Measures in its next
public reporting cycle.
Table 11: Statement 8 Responses
Category

Details

PM Pre-Fill

Insert Text

Self-Assessment

Change, No Change, or NA

Explanation of Self-Assessment

Insert Text

Element 3.3
Identify changes to the design of reports for providers and the public.
Statement 9: Your organization would like to change the content or appearance of its providers or
public report during its next reporting cycle. A change is a significant modification in the provider ratings
approach, level of analysis for reported measures, comparative reporting by product line, or website
address, for example, but excludes changes due to the addition or removal of performance measures.
Table 12: Statement 9 Responses
Category

Details

PM Pre-Fill

Insert Text

Self-Assessment

Change, No Change, or NA

Explanation of Self-Assessment

Insert Text

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Statement 10: Your organization would like to change its dissemination plan for informing intended
audiences of the issuance of its QE performance reports. This includes anticipated changes to the public
report release schedule and frequency.
Table 13: Statement 10 Responses
Category
PM Pre-Fill

Details
Insert Text

Self-Assessment

Change, No Change, or NA

Explanation of Self-Assessment

Insert Text

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Appendix A: Additional Attachments
If you have additional attachments for to the Paper-Based Reapplication Form, attach them to the
submission email to QECP support.

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Appendix B: Minimum Requirements Review
The following tables detail Reapplication requirements.
Table 14Table 14 details Element 1.1: Identify changes to QE’s organization.

Formatted: Body Text Italic Char

Table 14: Element 1.1 Requirements
Program
Requirement
Assessment

Details
Statement 1: Your organization intends to continue to contract with the same
organization(s) to fulfill the QECP requirements.
Note: Public and non-public reports that include QE Medicare data must not be
disseminated using a new data analytics/warehousing vendor prior to the new vendor (and
lead QE) submitting updated QECP Phase 2 evidence and obtaining CMS approval (refer to
Program Guide Section 3.55.2).

Evidence
Required

If the organization plans to work with new/additional contractors, vendors, partners,
subsidiaries or member organizations, it must complete the QECP Letter of Commitment
including Appendix B: Contractual Relationship Attestation.

Example
Documentation



Letter of Commitment



Articles of Incorporation

Table 15Table 15 details Element 1.4: Identify changes to QE’s ability to obtain claims data from at least
one other source to combine with QE Medicare data.
Table 15: Element 1.4 Requirements
Program
Requirement
Assessment

Details
Statement 2: Your organization still receives the same sources and amounts of other-payer
claims data for the approved geographic areas in the pre-filled text box below.
Note: A QE may not, under any circumstances, use a measure, create a report, or issue a
report after the amount of claims data from other sources available to the QE decreases
until the QECP Team determines either 1) that the remaining claims data are sufficient, or 2)
that the QE has collected adequate additional data to address any identified deficiencies
(refer to Program Guide Section 2.25.2).

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Reapplication Form

Program
Requirement
Evidence
Required

Details


If the geographic area has changed, the organization must submit a new QECP Data
Source Attestation.



If the amount of other-payer claims data received by the organization has increased, it
must submit a new QECP Data Source Attestation.



If the amount of other-payer claims data received by the organization has decreased, it
must submit a new QECP Data Source Attestation.
 In addition, it must provide an explanation, by data supplier name, of the reason
why the data source is no longer available to the organization, or the reason why
the amount of data received by the supplier has decreased.
 It must submit documentation that demonstrates that the remaining claims data
from other sources are sufficient to address methodological concerns regarding
sample size and reliability.

Example
Documentation

NA

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Table 16Table 16 details Element 2.1: Identify changes to QE’s data security and privacy policies and
procedures.

Formatted: Body Text Italic Char

Table 16: Element 2.1 Requirements
Program
Requirement
Assessment

Details
Statement 3: The data flow diagram submitted by your organization still accurately
demonstrates 1) how sites that access the QE Medicare data are connected and 2) how QE
Medicare data flow through your organization from receipt to public reporting (including
the confidential provider Corrections and Appeals process).
Statement 4: Since Phase 2 approval, or submission of your organization’s most recent
QECP Annual Report, your organization has made significant changes to the data security
environment and practices.
A significant change is an action that is likely to affect the security state of an information
system or its environment of operation; some examples include, but are not limited to:

Evidence
Required

Example
Documentation



Modifications to cryptographic modules or services



Modifications to security controls



Moving to a new facility



Change in vendors, business partners, or service providers



Changes in data hosting providers



Changes in staff with primary responsibility for data security



Data breaches and other violations of the CMS DUA



Acquiring specific and credible threat information that the organization is being
targeted by a threat source



Establishing new/modified laws, directives, policies, or regulations



If there is any uncertainty about whether a change in a data security program is
significant and should therefore be reported, consult with the QECP Team to
determine the appropriate next steps.



If the organization has experienced a change to its security environment through which
QE Medicare data flows, it must submit an updated, annotated QE data flow diagram.



If the organization experienced a change to its data security environment or practices,
it must provide an explanation of the changes, including the date when each change
occurred.



Data Flow Diagram



Policies and Procedures

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Table 18Table 17 details Element 2.2: Identify Changes to QE’s Public and Non Public Reporting Levels
Table 17: Element 2.2 Requirements
Program
Requirement

Details

Assessment

Statement 5: Your organization’s attestations provided in the Application still accurately
demonstrate your planned level of reporting (regional or provider identified) within public
reports and non-public analysis.

Evidence
Required

Evidence includes the following items:

Example
Documentation



If the organization would like to report publicly or non-publicly at the provider level and
had previously reported at a regional level, it must provide a Corrections and Appeals
process including the process that would allow an entity to securely transmit
beneficiary claims to providers.



If the organization would like to report publicly or non-publicly at the regional level and
had previously reported at a provider level, it must provide an explanation of the
masking methodology that would prevent providers from being re-identified.

NA

Table 18 details Element 2.3 and Element 2.4: Identify changes to Corrections and Appeals process,
identify any changes related to secure transmission of beneficiary data.
Table 181718: Elements 2.3 & 2.4 Requirements
Program
Requirement
Assessment

Details
Statement 5: Your organization would like to change their level of reporting (provideridentified vs regional) prior to the next reporting cycle for either public or non-public
reports.
Statement 6: Your organization would like to make a change to their Corrections and
Appeals process prior to the next reporting cycle; this includes any changes to your
organization’s privacy and security protections for the release of beneficiary identifiers
and/or claims data to providers. If providers are de-identified in QE public reports or NPAs:
Your organization would like to make a change to its masking methodology.

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Reapplication Form

Program
Requirement
Evidence
Required

Example
Documentation

Details


If the organization would like to report publicly or non-publicly at the provider level and
had previously reported at a regional level, it must provide a Corrections and Appeals
process including the process that would allow an entity to securely transmit
beneficiary claims to providers.



If the organization would like to report publicly or non-publicly at the regional level and
had previously reported at a provider level, it must provide an explanation of the
masking methodology that would prevent providers from being re-identified.



If the organization is planning to make changes to the confidential provider Corrections
and Appeals process, it must provide an explanation describing the changes; these
changes must be reflected in the QE data flow diagram provided under Statement 3;
changes related to contractual relationships with data analytics/warehousing vendors
are subject to the requirements of Statements 1 and 3.

NA

Table 18Table 19 details Element 3.1: Identify changes to Standard Measures QE intends to report in
next public reporting cycle.
Table 1819: Element 3.1 Requirements
Program
Requirement
Assessment

Details
Statement 7: Your organization intends to continue reporting the same Standard Measures
in its next public reporting cycle.
Note: QEs must notify the QECP Team of any new Standard Measures they wish to add to
their approved list of measures at least 30 days before the intended confidential
performance release to providers for the corrections and appeal process (refer to Program
Guide Section 5.12).

Evidence
Required

Example
Documentation



If the organization would like to change the Standard Measures that have previously
been publicly reported, it must provide an explanation of the Standard Measures that
will be added or removed in the next public reporting cycle.



For measures that will be added, the organization must submit a revised QECP
Measure Information Workbook, accompanied by the required supporting
documentation for Element 3.1.

NA

Table 20Table 19 details Element 3.2: Identify changes to Alternative Measures QE intends to report in
next public reporting cycle.

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Table 1920: Element 3.2 Requirements
Program
Requirement
Assessment

Details
Statement 8: Your organization intends to continue reporting the same Alternative
Measures in its next public reporting cycle.
Note: QEs are required to notify the QECP Team of any Alternative Measures they wish to
add to their approved list of measures; QEs must notify the QECP Team of any new
Alternative Measures at least 60 days before the intended confidential performance report
release to providers) and are strongly encouraged to notify the team up to 90 days
beforehand (refer to Program Guide Section 5.12).

Evidence
Required

If the organization would like to change the Alternative Measures that have previously been
publicly reported, it must provide an explanation of the Alternative Measures that will be
added or removed in the next public reporting cycle; for measures that will be added, it
must submit a revised QECP Measure Information Workbook, accompanied by the required
supporting documentation for Element 3.2.

Example
Documentation

NA

Table 20Table 21 details Element 3.3: Identify changes in design of reports for providers and the public.
Table 2021: Element 3.3 Requirements
Program
Requirement
Assessment

Details
Statement 9: Your organization would like to change the content or appearance of its
provider or public report during its next reporting cycle (a change is a significant
modification in the provider ratings approach, level of analysis for reported measures,
comparative reporting by product line, or website address, for example, but excludes
changes due to the addition or removal of performance measures.).
Note: QEs must notify the QECP Team of changes to the provider and/or public prototype
report, and submit to the QECP Team the new prototype report(s) at least 630 days before
the intended confidential release to providers (refer to Program Guide Section 5.32).
Statement 10: Your organization would like to change its dissemination plan for informing
intended audiences of the issuance of its QE performance reports. This includes anticipated
changes to the public report release schedule and frequency.
Note: QEs must notify the QECP Team of changes in the dissemination plan for sharing
reports with the public and submit the new plan at least 630 days before the intended
confidential performance report release to providers (refer to Program Guide Section 5.32).

Evidence
Required



If the organization would like to make changes to the content or appearance of
provider and/or public reports, it must provide an explanation of the changes, and
submit the revised provider and/or public report prototype.



If the organization would like to make changes to the dissemination plan, it must
provide an explanation of the changes.

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Program
Requirement
Example
Documentation

Details
NA

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